Afrisys 

iBurst Rental

iBurst Rental Package Order Form @ Afrisys

Rental Subscriber Details

Subscriber/Business Name* 
ID/Registration Num*

  Copy for Proof may be required

Physical Address* 
  
City/Town* 

P/Code*

 
Postal Address* 
City/Town* 

P/Code*

 
Contact / User* 
Telephone (Office)* Telephone (Home)* 
Telephone (Mobile/Cell)* Telephone (FAX)* 
e-Mail 1* e-Mail 2 (Alternate) 

Subscriber References

Account Reference 1* Telephone* 
Account Reference 2* Telephone* 

Rental Service Plan Details

Modem Type*

            Quantity*         

Package Size*

Router 

Date Required

 
Rental Period*

 

Delivery

 

 

* Required Fields

By clicking on submit, I confirm the accuracy of the information contained in this web-based document and I warrant that I am duly authorised to submit on behalf of the subscriber. I acknowledge that I have read, understand and agree to be bound by the terms and conditions as contained on this site. I hereby warrant to pay to Afrisys the amounts due for Services and for Modem . I hereby consent to WBS and/or Afrisys to perform a Credit Check on me/us.

Please Note! All Delivery, Installation and Setup fees are for the subscriber's Account

Terms & Conditions

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 info@afrisys.org
Tel 083 949 7320
Fax 086 686 9842

Last Updated: 2010-09-06

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